Joint Commission Patient- Centered Communication Standards

Joint Commission Patient-Centered Communication

Standards

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Speaker

Sue Dill Calloway RN, Esq. CPHRM AD, BA, BSN, MSN, JD

President Patient Safety and Healthcare Education 5447 Fawnbrook Lane Dublin, Ohio 43017

614 791-1468 [email protected]

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Study Finds Few Hospitals in Compliance

Study published February 14, 2011 finds few hospitals in compliance with the TJC standards on patient centered communication

Lack of compliance with language access requirements for limited English proficiency (LEP)

Communication breakdowns are responsible for 3,000 unexpected death every year

Standards to improve patient provider communication and ensure patient safety "The New Joint Commission Standards for Patient-Centered Care," report

can be found at http://www.languageline.com/jointcommission2011report

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Topics Covered in the White Paper

Language challenges that impact healthcare

Why language services are critical

The unfortunate truth: most hospitals are not compliant

The origins of medical interpreting

Patient/provider understanding and acceptance

Joint Commission mandates for training and certification

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Topics Covered in the White Paper

The standards that apply to language access services

The consequences of non-compliance

Developing a system-wide language services program

The Joint Commission is serious

Hospitals CAN prepare themselves

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Introduction Patient-Centered Communication standards were

approved in December 2009

Surveyors will evaluate compliance with the standards on January1, 2011

However, findings will not affect the accreditation decision Information will be used during this pilot phase to prepare the

field for implementation questions and concerns

Compliance in the accreditation decision will be no earlier than January 2012

Except visitation (EP 28 and 29) will be effective July 1, 2011

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http://www.jointcommission.org/patientsafety/hlc/

TJC R3 Report

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http://www.jointcommission.org/R3_issue1/

Introduction It is essential that healthcare providers and their

staff be able to communicate effectively with one another to provide quality patient-centered healthcare

Studies show that failure to communicate is the major root cause of medical errors

Ineffective communication leads to misdiagnosis and inappropriate treatment

It leads to unnecessary readmissions

By 2012 hospitals with a higher rate of readmission will be financially penalized

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Introduction

IOM report “Unequal Treatment (2002)” tied alarming results to language barriers

Patients receive lower quality of medical care resulting in overall poorer health

Language barriers result in miscommunication and poor decision-making

This leads to fewer physician visits and missed appointments

Leads to prescription medication errors

Leads to repeat emergency department visits

Results in reduced use of preventative services12

Introduction

Hospitals and other healthcare facilities will encounter more patients with language barriers as our country becomes more diverse

Hospitals must have language access services for translators and interpreters to meet the communication needs of patients

Communication is a critical part of patient safety and risk management

This is what lead the Joint Commission to adopting standards in four different chapter on patient centered care to ensure patient provider communication

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Introduction Case in Point

Case received national media attention

18 year old comes to hospital stating “intoxicado”

Patient was misdiagnosised as being intoxicated

It has several meanings but patient was nauseated

An interpreter was not consulted

Resulted in quadriplegia from a brain aneurysm

Patient awarded a $71 million dollar verdict against the Florida hospital

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Language Access Plan HHS regulations require the plan for LEP patients (non-

English speaking, Limited English Proficiency) to use four factors:

Number of patients with limited English skills served Safe harbor standard of 5% in translation of documents

Frequency of visits

Importance of service provided

DOJ brief: informed consent discussion, discharge instructions, insurance and billing information, diagnostic tests, prognosis, physician rounds, mental health, surgery etc.

Available resources and costs Large hospital the cost would not be a burden

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Introduction Translators and interpreters are different

Safe Harbor standards talks about doing this if 5% of your population speaks another language

Interpreter converts one spoken language into another – In the case of sign-language interpreters between the spoken work

and sign language

Translators deal with the written words Will take documents and translate them in another language

such as Spanish

Need excellent writing and editing skills16

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Introduction Limited English proficiency is abbreviated LEP

LEP means the patient is unable to communicate effectively in English

Because their primary language is not English

And they have not developed fluency in the English language

For example, the patient may speak Spanish and no English at all or limited English

The US Department of Health and Human Services (HHS) has resources on the Office of Civil Rights (OCR) website

http://www.hhs.gov/ocr/civilrights/resources/specialtopics/lep/

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Introduction

What is your language access plan?

Are all staff educated on the hospital’s language access plan and language access services?

Do you have a language access coordinator?

Is staff educated on the hospital’s policy and procedure?

Are translators and interpreters qualified and have formal education and training and assessed ?

Is use of an interpreter documented in the medical record?

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Introduction

Have you assessed the language assistance needs of your LEP patients and the capacity to meet the needs according to your plan?

Do you use interpreters during vital or critical parts of care to ensure proper communication?

Do you use written translators to produce vital documents in languages other than English when a significant number or percentage of patients served had LEP?

Do you inform LEP patients of the availability of free language services?

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Introduction

Does the Human Resource Department maintain files for all interpreters regardless of their employment status?

Could your hospital provide surveyors with documentation that each interpreter has undergone competency assessment during the tracer reviews?

Remember that the OCR and DOJ consider it a violation of Title VI when LEP patients are denied meaningful access to care due to language barriers

OCR is the Office of Civil Rights and DOJ is the Department of Justice

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TJC Patient-Centered Communication

Joint Commission has standards in the following four chapters with two in the Patient Rights chapter;

Human Resources

– HR.01.02.01

Provision of Care

– PC.02.01.21

Patient Rights

– RI.01.01.01 and RI.01.01.03

Record of Care

– RC.02.01.01

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HR.01.02.01

Standard: The hospital defines staff qualifications

Qualifications for language interpreters and translators may be met through language proficiency assessment, education, training and experience

Hospital has flexibility to define the qualifications for their interpreters and translators

– The use of qualified interpreters and translators is supported by the ADA, Section 504 of the Rehabilitation Act of 1973, and Title VI of the Civil Rights Act of 1964

– The federal laws will be discussed later

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HR.01.02.01 Examples

Someone who is fluent in Spanish and has attended a minimum 40 hour education class is qualified to be an interpreter

There is no current national certification specifically for healthcare interpreters

However, two organizations were formed to meet the needs for providing certification of professional competence that meet national standards of knowledge, skill, and performance for healthcare interpreters

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HR.01.02.01 Examples There are now two organization that provide

certification of professional competence in Spanish

First one in September 2009

– Certification Commission for Healthcare Interpreters CCHI

Second one effective January of 2011

– It is an oral and written exam from National Board of Certification

– So now this person is qualified and certified

– Offered only in Spanish but other languages forthcoming

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Education Content of Programs CCHI

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Qualifications to Take Exam CCHI

Healthcare Interpreters must meet the following eligibility requirements before they can apply for the examination. Minimum age of 18 years.

At least one year of experience working as a healthcare interpreter.

Have a minimum of U.S. high school diploma (or GED) or its equivalent from another country.

Have at least 40 hours of healthcare interpreter training (academic or non-academic program).

Have linguistic proficiency in English and the target language(s).

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HR.01.02.01 How to Meet the Standard

HR should be aware of the certification status

Current confusion around issue of certification

ATA has program for translators of documents but current passage rate is only about 20%

Certification exists for American sign language (ASL) for the deaf

New emerging area for interpreters for standards for new interpreters education

Many formal programs and colleges adding this to their curriculum

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Certification and Meeting the Standard HR should make sure medical interpreters have formal

education and be trained and assessed in medical interpretation and experience

HR should maintain a file on all interpreters regardless of their employment status

Same level of documentation with remote telephone or video language service providers

American Sign Language (ASL) interpreters may receive national certification through a joint program of the Registry of Interpreters for the Deaf (RID) and the National Association of the Deaf

The ASL interpreter certifications is not specific to health care30

Certification CHI AHI CMI QMI SMI National Council on Interpreting in Health Care and

CCHI or the Certification Commission for Healthcare Interpreters (CCHI Associate Healthcare Interpreter credential and has two credentials)

CHI stands for Certified Healthcare Interpreter (best)

AHI stands for Associate Healthcare Interpreter

The National Board of Certification for Medical Interpreters

CMI or Certified Medical Interpreter, Qualified Medical Interpreter (QMI) or Screened Medical Interpreter (SMI)

Question contact [email protected]

Two Credentials of CCHI

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www.healthcareinterpretercertification.org/

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Certification for Interpreters Many people use this term “certified interpreter”

when they only attended an education program

Participants will receive a certification of attendance or participation which has been confused with being certified Certification is a formal process by which a governmental,

academic or professional organization attests to an individual’s ability to provide a particular service.

Certification calls for formal assessment, using an instrument that has been tested for validity and reliability, so that the certifying body can be confident that the individuals it certifies have the knowledge, skills and abilities needed to do the job.

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Certification for Interpreters

Initial work done in a pilot program by the Massachusetts Medical Interpreters Association (MMIA, now the IMIA)

Funded by the U.S. Office of Minority Health

Done in collaboration with the California Healthcare Interpreters Association (CHIA) and the National Council on Interpreting in Health Care (NCIHC)

The Certification Commission for Healthcare Interpreters is continuing their mission to develope certification for health care interpreters

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Proposed National Training Standards

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Certification for Translators However, ATA or the American Translators

Association, has a general certification program to enable individual translators to demonstrate that they met professionals standards

ATA certification is awarded to candidates who pass an open book exam

Is a testament to translator’s competence in translating one specific language to another

Source: A Guide to Understanding Interpreting and Translation in Health Care by NCIHC

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Guide to Understanding Interpreting

A Guide to Understanding Interpreting and Translation in Health Care is an excellent resource for HR staff

Has requisite skills and qualifications of a translator and an interpreter

Discusses certification for interpreters and translators

Discusses how to hire an interpreter or translator

Discusses standards of practice for an interpreter and a translator

What skills are needed for interpreters and translators39

www.ncihc.org/mc/page.do?sitePageId=57022

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http://www.ncihc.org/mc/page.do;jsessionid=EC5D32E43B90F9742B4E5C91472A5142.mc1?sitePageId=50909

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How to Hire an Interpreter

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PC.02.01.21 Standard: The hospital communicates with patients

when providing care

Rationale:

Patient-provider communication is important for patient safety

Studies show patients with communication programs are at an increased risk for medical error

70% of all errors have found the root cause to be communication errors

Patients with LEP are more likely to have an adverse event than English speaking patients

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Resources Bartlett G, Blais R, Tamblyn R, Clermont RJ,

MacGibbon B: Impact of patient communication problems on the risk of preventable adverse events in acute care settings. CMAJ 178(12):1555-1562, Jun. 3, 2008

Divi C, Koss RG, Schmaltz SP, Loeb JM: Language proficiency and adverse events in U.S. hospitals: A pilot study. Int J Qual Health Care 19(2):60-67, Apr. 2007

Cohen AL, Rivara F, Marcuse EK, McPhillips H, Davis R: Are language barriers associated with serious medical events in hospitalized pediatric patients? Pediatrics 116(3):575-9, Sep. 2005

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PC.02.01.21 EP1 Hospital identifies the patient’s oral and written

communication needs

This includes the patient’s preferred language for discussing healthcare

Patient may have hearing needs and need an amplifier on the phone or have their hearing aid brought in

Patient may be hearing impaired and need a deaf interpreter or TDD phone (telecommunication device)

Patient may have visual needs and need enlarged copies of important document or magnifying glasses or glasses brought to the hospital

Patient may be intubated and need white board to write on45

PC.02.01.21

Hearing impaired patient (deaf or HOH) may need a sign language interpreter

Ask the patient “Do you have any hearing aids, glasses or other devices you use routinely to communicate?”

Reading some of the DOJ and OCR settlement agreement give lots of ideas hospitals can do to provide equipment or auxiliary aids and services to ensure good patient provider communication (see later)

Hospital may want to include this question on their ED triage form and admission assessment form

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PC.02.01.21

EP2 Hospital communicates with the patient in a manner that meets the patient’s oral and written communication needs

Patients get to converse in the language they pick

This is patient centered care because the focus is on what the patient wants

The focus is not on what is easiest for the hospitals

Need to find out what language the patient refers to converse in such as patient requests Spanish

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PC.02.01.21

Once patients communication needs are identified then hospital can determine how to best meet these needs

Identify the preferred sign language for the patient who uses sign language to communicate

For example, American Sign Language, or Signed English or use of Braille

For patients who are deaf or hard of hearing and have limited English proficiency, a sign language from another country

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PC.02.01.21 Ideas

Have a patient handbook

Have a P&P on interpreters and translators

Make sure staff educated on P&P during orientation and annually including ED training

Make sure staff know how to easily access interpreters

Ensure prompt call for interpreters such as call within 10 minutes

Want to ensure an interpreter is present during vital or critical parts of care

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PC.02.01.21 Ideas

Vital or critical parts of care

might include informed consent discussions, H&P, explanation of advance directives, discharge, explanation of procedures and tests, explanation of new medications and how to take, explanation of follow up treatment, provision of behavioral health assessment, education, blood or organ donation etc.

Make sure the sign language interpreter is qualified

Do not use a child or family member

Use captioned televisions

Special measures for deaf or HOH rea fire alarms50

PC.02.01.21 Ideas

Have signs in several different languages that interpreting services are available at no charge to the patient

Monitor patient satisfactions with interpreting services and include in PI process

Make sure patients understand the hospital’s grievance and complaint process (CMS & TJC standards)

Consider having a interpreting/translation service coordinator

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PC.02.01.21 Ideas Determine if the patient needs assistance

completing admission forms

40% of patient have significant literacy challenges

88% of adult have less than proficient health literacy skills

Careful if says “I forgot my glasses”

Ask the patient “Would you prefer to have someone help you fill out the forms?”

Ask patient if any additional needs that may affect their care

“Is there anything the hospital should be aware of to improve your care experience?”

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PC.02.01.21 Ideas

Identify if the patient uses any type of assistive devices such as canes, walkers, service animal, or other mobility devices

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RC.02.01.01

Record of care was a new chapter in 2009

Often referred to as the documentation chapter

Standard: The medical record must contain information that reflects the patient’s care

EP 1 Includes information that the medical record must contain regarding demographics

Patient’s name, address, date of birth, sex, etc

Added the patient’s communication needs including preferred language for discussing health care

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RC.02.01.01

The PC chapter required hospitals to ask about their preferred language for discussing health care

Ask the patient “In what language do you prefer to discuss your healthcare.”

The RC chapter requires that you document the information received

If patient is a minor then ask the parent

If patient has a DPOA or guardian because they are incapacitated then check with them

If patient speaks English but guardian, DPOA, or parent does not then you need to ask them what is their preferred language

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RC.02.01.01 EP 28 has been added to make sure hospitals now

collect and document information on

The patient’s race and ethnicity

Allow the patient to self report race and ethnicity

This information is useful in understanding cultural issues so add to data collected on admission

An assist as a starting point to ask additional questions related to communication

Helps to determine what documents should be translated and to plan for interpreting services

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RC.02.01.01

Can help hospitals monitor and analyze health disparities at the population level

Make sure patients know why race and ethnicity are being collected

The Health Research and Educational Trust recommends that staff explain to the patient

“We want to make sure that all our patients get the best care possible, regardless of their race or ethnic background. We would like you to tell us your race or ethnic background so that we can review the treatment that all patients receive and make sure that everyone gets the highest quality of care”

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RI.01.01.01

Standard: Hospital respects, promotes, and protects patient rights

EP28 The hospital allows a family member or friend to be with patient during the course of stay for emotional support

As long as does not infringe on the other patients’ rights

Does not have to be the patient surrogate or legal decision maker

CMS has changes to the hospital CoP regarding visitation rights

Patients should be able to define who they want to visit58

RI.01.01.01 Hospital must have written policies on patient rights

Hospital must inform patients of these rights

Including written notice of visitation rights

Including written notice of right to contract QIO and state agency with full address, phone number and email address and document both in the medical record

Written translations of those rights should be available in common languages

Hospitals must be respectful of patients’ cultural and personal values, religious beliefs, spiritual beliefs and right to privacy

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Visitation Law in a Nutshell CMS CoP

Require all hospitals that accept Medicare or Medicaid reimbursement

To allow adult patients to designate visitors

Not legally related by marriage or blood to the patient

To be given the same visitation privileges as an immediate family member of the patient

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Visitation Rights for All Patients CMS issued proposed changes to the CAH and

PPS hospital conditions of participation (CoPs)

Published in the June 28, 2010 Federal Register (FR) with comments until August 27, 2010

Had 7,600 comments but 6,300 were form letters

CMS publishes the final rule in the November 18, 2010 FR

Regulation effective January 18, 2011

Applies to all hospitals that accept Medicare and Medicaid reimbursement

This includes all critical access hospitals61

Visitation Rights for All Patients CMS issues final changes to the CAH and PPS

hospital conditions of participation (CoPs)

Effective January 18, 2011

This rule revises the hospital CoPs to ensure visitation rights of all patients including same sex domestic partners

Hospitals are required to have policies and procedures (P&P) on this

P&P sets forth any clinically necessary or reasonable restrictions or limitations

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Visitation Rights for All Patients

The final rule implements the April 15, 2010 Presidential memo1

The President gave HHS (Health and Human Services) the task of requiring any hospital that receives Medicare reimbursement to preserve the rights of all patients to choose who can visit them

Patients or their representative have a right to visitation privileges that are no restrictive than those for immediate family members

1 http://www.whitehouse.gov/the-press-office/presidential-memorandum-hospital-visitation

2 http://www.access.gpo.gov/su_docs/fedreg/a100628c.html (June 28, 2010 Federal Register)

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Sample Visitation Authorization

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RI.01.01.01

EP 29 The hospital prohibits discrimination based on;

Age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression

So TJC and CMS will be consistent with their standards on preventing discrimination regarding visitors

The patient defines who their family is and who they want to visit and be with them at the hospital

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RI.01.01.01

Remember the Joint Commission has the speak up campaign

One of these talks about having a trusted friend to be your advocate

Patients can sometimes not remember things later on

Some patients more comfortable if someone with them constantly to support them including in the ICU

One of the 34 Safe Practices for Better Healthcare66

www.jointcommission.org/PatientSafety/SpeakUp/

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Have a Trusted Friend be Your Advocate

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RI.01.01.03

Standard: The hospital respects the patient’s right to receive information in a manner he or she understands

EP2 The hospital provides language interpreting and translation services

Hospitals may use hospital employed language interpreters

Hospitals can train their bilingual staff to be an interpreter

Hospitals can contract with an interpreting service

Options can be by phone or video

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RI.01.01.03

The hospital needs to document which translated documents and languages are needed based on its patient population

EP3 The hospital provides information to the patient who has speech, vision, hearing, or cognitive impairments in a manner that meets the patient’s needs

Changed from communicates with the patient to provides information to the patient

Want to make sure patients understand discharge instructions, consent issues, education, and other important parts of care at the point of care

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What are Surveyors Looking For? The hospital has a P&P on language access

services

That staff are oriented and trained in the P&P

That language access is used at the critical times or points of care and staff know how to access these

That staff and physicians understand the patient has the legal right to interpreting and translation services

How the hospital designed the program and addition to their demographics with the population served

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What are Surveyors Looking For?

Surveyors will observe if staff follow the P&P to make sure patients communication needs are met

May do as part of a tracer and select a patient who does not speak English

What is the hospital’s plan for language access, accessibility and that it is in good working order

Make sure bilingual staff have training on how to be an interpreter

Remember discussion about not using a child to interpret and issue about family members

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Will make sure patients are informed about their rights and consider posting sign

Will verify there is documentation about the use of an interpreter

Will verify that there is documentation about the patient’s preferred language for discussing health care

That race and ethnicity data is collected in the MR

Will assess if the patient uses any assistive devices and these were used to help the patient

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Consider providing patient rights materials in multiple language along with other important documents for patient population served

Identify patient cultural, religious, or spiritual beliefs and practices that influence care

The Roadmap for Hospitals has a number of excellent recommendations for ensuring a quality interpreting and translation program

This is available at no charge

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Advancing Effective Communication Roadmap

Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals is a monograph developed by TJC

To help hospitals incorporate concepts from the communication, cultural competence, and patient- and family-centered care fields into their facility

The Roadmap will help hospitals to comply with the patient-centered communication standards

Has educational tools

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Communication Roadmap

Includes information on the law

Includes model policies

Includes a self assessment guide

Provides examples for each standard

Roadmap Updated August 2010

See also Hospitals, Language, and Culture A Snapshot of the Nation

See One Size Does Not Fit All: Meeting the Healthcare Needs of Diverse Populations

Available at http://www.jointcommission.org/patientsafety/hlc/76

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Roadmap for Hospitals

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Tool for Communication Assessment

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Checklist for Effective Communication

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OIG Examines Provisions of Language Services

Medicare Improvements for Patients and Providers Act of 2008 requires survey of hospitals and others with high number of limited English proficient individuals (LEP)

Only 2/3 of hospitals use the Office of Civil Rights four factor assessment to determine which language services are appropriate for a patient

Only 33% of providers offered services consistent with the Office of Minority Health's Culturally and Linguistically Appropriate Services in Health Care voluntary standards

Report OEI-05-10-00050 issued July 2010 at www.oig.hhs.gov

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Federal Laws Title VI of the Civil Rights of 1964 prohibits discrimination

on the basis of race, color, and national origin

OCR and DOJ hold that LEP patients are denied meaningful access to care due to language barriers

Section 504 of the Rehabilitation Act of 1973

Title II of the Americans with Disabilities Act (ADA) of 1990 prohibits discrimination on the basis of disability

Title III of the Americans with Disabilities Act of 1990 prohibits discrimination on the basis of disability by places of public accommodation and commercial facilities

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Where to Find These Federal Laws

28 CFR PART 35: Implementing Title II of the Americans with Disabilities Act of 1973

Prohibits discrimination on the basis of disability in state and local government services

This includes public hospitals

OCR has easy to read fact sheets on each of these

http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=4f19a78b9f025ef7dede0f0838b07a60&rgn=div5&view=text&node=28:1.0.1.1.36&idno=28

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Facts Sheets Available for Federal Laws

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www.hhs.gov/ocr/civilrights/resources/factsheets/index.html

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Where to Find These Federal Laws 45 CFR Part 84: Implementing Section 504 of the

Rehabilitation Act of 1973

Prohibits discrimination on the basis of disability in programs or activities that receive financial assistance from the Department of Health and Human Services (DHHS)

Includes requirement to provide effective communication to HOH and deaf as long as not an undue financial burden

Includes Medicare and Medicaid so almost all hospitals

http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr;sid=220613de0484d6b142952b87827e70b2;rgn=div5;view=text;node=45%3A1.0.1.1.43;idno=45;cc=ecfr

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Where to Find These Federal Laws

45 CFR Part 80: Implementing Title VI of the Civil Rights Act of 1964

This is the oldest of the laws that prohibit discrimination

Prohibits discrimination on the basis of race, color, or national origin in programs or activities that receive financial assistance from HHS

Includes those with limited English proficiency (LEP)

http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr;sid=220613de0484d6b142952b87827e70b2;rgn=div5;view=text;node=45%3A1.0.1.1.39;idno=45;cc=ecfr

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Where to Find These Federal Laws 28 CFR Part 36: Implementing Title III of the Americans

with Disabilities Act (ADA) of 1990

Prohibits discrimination on the basis of disability by places of public accommodation and commercial facilities

ADA home page at www.ada.gov with Title III changes March 15, 2011

http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr;sid=f461831d48ff742430cc5bc14cbc2d9b;rgn=div5;view=text;node=28%3A1.0.1.1.37;idno=28;cc=ecfr

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TJC Video Improving Patient-Provider Communication

The Joint Commission and the HHS Office of Civil Rights has a resource that hospitals should be aware of

It is a 31 minute video on how to improve patient-provider communication

It is available at no charge

Initially standard referred to as patient-provider communication

More recently referred to as patient-centered communication

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TJC Video Improving Patient-Provider Communication

Website notes that hospitals and healthcare facilities need to change to meet the needs of an increasingly diverse patient population

28 million people have hearing loss

47 million people speak a language other than English

Increased number of patients with low health literacy (low English proficiency)

20% of the population read at the fifth grade level

Discusses the federal civil rights law97

Office of Civil Rights

Office of Civil Rights (OCR) has a number of helpful resources for hospitals

Collaborated with the American Hospital Association (AHA) to publish the Effective Communication in Hospital Initiative

Each of the ten regional offices and at least one state hospital association are collaborating to development of a program to help hospitals

This is to help hospitals meet the needs of their patients

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www.hhs.gov/ocr/civilrights/resources/specialtopics/hospitalcommunication/ecinfo.html

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www.hhs.gov/ocr/civilrights/resources/specialtopics/hospitalcommunication/index.html

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Has 4 core elements of the collaboration

Assessment of the issues and concerns of the state’s hospitals regarding effective communication with the target populations

Development and implementation of educational and other activities to effectively and efficiently improve language access for the target populations

Evaluation of both the process and the outcomes of the collaborative efforts

Sharing the results of these efforts in a manner that will assist other hospitals and state associations facing similar issues nationwide

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17 State Hospital Associations Collaborating

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OCR will provide training related to responsibilities required by federal law

OCR will provide information related to both laws and best practices

OCR and AHA are partnering to make sure all hospitals have access to the resource materials to ensure that all patients are provided effective communication

Also has a section on FAQ about effective communication in hospital initiatives

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Office of Civil Rights FAQ

OCR has a mission statement to ensure that all patients have access to healthcare without facing unlawful discrimination

OCR wants to give hospitals the tools it need to make sure communications are effective with patients who are deaf, hard of hearing (HOH), or have low English proficiency (LEP)

May have additional state hospitals join later on

Has a website for regulations, fact sheets, videos, and examples of compliance

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HRET Report

AHA Health Research and Education Trust (HRET) did a report based on a survey

Report was called Hospital Language Services Survey

Purpose is to help hospitals develop and implement a effective communication program with the target populations (HOH, deaf, LEP)

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Cases

Website to include

OCR selected disability cases

OCR selected Limited English Proficiency Cases

Department of Justice (DOJ) settlement agreements

Available at http://www.hhs.gov/ocr/civilrights/resources/specialtopics/hospitalcommunication/heccomplianceactivities.html

OCR can refer cases to DOJ for civil money damages and to get a consent agreement

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Cases

Yale New Haven Hospital-OCR gets a resolution agreement after concerns about hospital outpatient departments failure to follow interpreter services policy and will ensure meaningful access by LEP patients

Erie County Medical Center Psychiatric Department-OCR gets resolution agreement after failure to provide language interpreter to homeless Spanish speaking patient during vital parts of care

Changed their policy and procedure

Developed alert system to ensure P&P is followed107

Cases Marin General Hospital in Ca-Spanish speaking

LEP filed complaint alleging discrimination on basis of national origin because did not speak English and hospital failed to provide him an interpreter during vital care during his hospital care and when given discharge instructions

Hospital made many changes

Revised P&P on providing language assistance to LEP patients, translates discharge instructions into Spanish

All new employees trained in interpretation

Appointed a translation service coordinator to oversee program, hospital signage in Spanish

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Cases Rheumatology Patient Rheumatologist Dr. Robert Fogari refuses to provide an

interpreter for Medicaid patient Irma Gerena who was seen 20 times for lupus

States only paid $59 per visit and interpreter wanted $150 to $200 per visit

No allegation of any negligence but that she was deprived of opportunity to participate and understand her medical condition

Sued under ADA and NJ law against discrimination

Jury awards patient $400,000 ($635,000 with attorney fees)

Most malpractice insurance does not cover such liability109

www.law.com/jsp/article.jsp?id=1202425326286

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The Leading NJ Case

The leading NJ case on the issues was an appellate court decision from 2001

Borngesser v. Jersey Shore Medical Center, 340 N.J. Super. 369

Court differentiated between critical points (vital) when a doctor or hospital must provide services

These are needed when doing things such as taking an H&P and getting informed consent (also remember HHS Guidance which includes discharge instructions, complaint form, eligibility for benefits, notice of free language assistance, intake form etc)

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The Leading NJ Case

During critical points (vital parts) provide auxiliary aids and services

Interpreters and bilingual staff

Video test displays

Note takers

Handset amplifiers

Video interpreting services

Open and closed captioning

Transcription services

Sign language112

Interpreters

Interpreters do more than simply translate words

They relay concepts and ideas between the two languages

Used for patients with limited English proficiency

They must understand the subject matter in which they work to accurately convey information from one language to another

They must be sensitive to the cultures associated with their language of expertise

Recommend that all interpreters be qualified113

Interpreters

Have a sign in different languages that interpreting services are available at no cost to the patient

Do not use children or family members to interpret

DOJ says this is inappropriate

HHS has a guidance that discusses this

If patient insists on a family member use interpreter to confirm

Have patient sign a waiver and be sure patient knows interpreting services are available at no cost to the patient

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Interpreters

Take reasonable steps to ensure there is

No confidentiality issues

They are competent to interpret

There are no conflicts of interest

Make sure medical record clearly documents the refusal

If use staff ensure there are trained in interpreting services and qualified

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Interpreters

Sign-language interpreters must be fluent in English and in American Sign Language (ASL)

This combines signing, finger spelling, and specific body language

Tactile signing is interpreting for people who are blind as well as deaf

By making manual signs into their hands, using cued speech, and signing exact English

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Department of Justice (DOJ)

Department of Justice has a website with resources on interpretation and translation

Has a section for medical

Hospitals should read some of the consent agreements for suggestions for their program

Includes a website for The National Council on Interpreting in Healthcare (NCIHC) Has proposed national standard for entry into practice for interpreters

in healthcare

Comment period closed October 29, 2010

http://www.lep.gov/interp_translation/trans_interpret.html117

118

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HHS Guidance for LEP Patients

The guidance was revised February of 2002

HHS released the guidance and for example told physicians to provide and pay for language interpreters in their offices

That is when hospitals and physicians and other healthcare facilities accept federal funds

Every hospital should have this guideline

Discussed the four factors that were previously discussed

DOJ published the LEP document

Discuss use of family or friends as interpreters120

www.hhs.gov/ocr/civilrights/resources/specialtopics/lep/policyguidancedocument.html

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Use of Families or Friends

122

What are Vital Written Materials

123

What Languages Should Documents Be….

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5% Rule in the Safe Harbor

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www.hhs.gov/ocr/civilrights/resources/specialtopics/hospitalcommunication/ecdoj.html

126

Hospitals should Read Settlement Agreements

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Code of Ethics for Interpreters

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www.formatex.org/micte2006/pdf/291-295.pdf

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www.corp.att.com/healthcare/docs/Paras.pdf

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http://www.bls.gov/oco/ocos175.htm

131

www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=id_016631#

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Reimbursement

Check with state agencies or health insurance plans regarding possible Medicaid or private reimbursement

States have the option of using Medicaid or Children's Health Insurance Program (CHIP) funds to cover interpreter costs

Currently only about a dozen states have chosen to do so according to the National Health Law Program

California became the first state to require health insurers to pay for interpreters for LEP patients

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TJC Resources

TJC has a number of excellent resources related to effective communication

Has resource list

Has 31 minute video on improving patient-provider communication

Has started a Joint Commission Center for Transforming Health Care

Has links to the OCR website resources

Article on promoting effective communication from Feb 2008 Perspective magazine

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Promoting Effective Communication Article

135

TJC Resources List

136

http://www.jointcommission.org/PatientSafety/HLC/video_improving_pt_provider_comm.htm

TJC Center for Transforming Healthcare

137

www.jointcommission.org/PatientSafety/HLC/video_improving_pt_provider_comm.htm

138

139

http://www.omhrc.gov/Assets/pdf/Checked/HC-LSIG.pdf

140

The End Questions???

Sue Dill Calloway RN, Esq. CPHRM AD, BA, BSN, MSN, JD

President Patient Safety and Healthcare Education 5447 Fawnbrook Lane Dublin, Ohio 43017

614 791-1468 [email protected]

List of State Interpreting Organizations

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Video

The Road to National Certification for Medical Interpreters

Discusses the success of the certification program

Discusses why hospitals need a qualified interpreter

Now available on YouTube http://www.youtube.com/watch?v=7zvlQNVof7U and through the

National Board website, www.certifiedmedicalinterpreters.org/

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Resources

143

http://www.certifiedmedicalinterpr

eters.org/

Resources and Update

National Board of Certification January 2011 newsletter discusses current new happenings

Oregon recognizes certification in their state for medical interpreters beyond Spanish

Working on oral certification testing and credentialing in five new languages; Cantonese, Mandarin, Korean, Vietnamese and Russian

National Board Certification exam just started and gets the title of “Certified Medical Interpreter” or CMI

See Registry of Certified Medical Interpreters at http://www.certifiedmedicalinterpreters.org/registry

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Registry of Certified Medical Interpreters

145

International Medical Interpreters Assoc IMIA

146

www.imiaweb.org/default.asp

Massachusetts Medical Interpreters Assoc MMIA

The oldest and largest medical interpreter association in the US being established in 1986

Pioneered the first medical interpreter code of ethics in 1987

Created the first medical interpreting standard of practice in 1992

In 2007 it reformed as the International Medical Interpreters Association or IMIA

Combined as IMIA with Language Line Services to do a medical certification on a national basis

147

Registry of Interpreters for the Deaf RID

Outlines practices and positions on interpreting roles and other related issues

Designed for ASL interpreters but does have some standards that apply to medical interpreters

Documents on professional sign language interpreting mentoring, mental health setting interpreting, interpreting for deaf and blind persons, video remote interpreting, video relay services, coordinating interpreters for conferences etc.

Go to http://www.rid.org/interpreting/Standard%20Practice%20Papers/index.cfm

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Registry of Interpreters for the Deaf

149

Hiring an Interpreter

150

www.rid.org/interpreting/hiring/index.cfm

151

www.netac.rit.edu/downloads/TPSHT_Hire_Qual_Interp.pdf

International Medical Interpreters Assoc

152

http://www.imiaweb.org/standards/RID.asp

CHIA Standards for Healthcare Interpreters

CHIA is California Healthcare Interpreting Association

Discusses the following;

Ethical principles for healthcare interpreters

Standardized interpreting protocols

Guidance on interpreting roles and interventions

Useful tool for training medical interpreters

Available at http://www.astm.org/Standards/F2089.htm

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California Healthcare Interpreting Association

154

155

A Guide for Understanding and Complying with the California Health

Care Plan Requirements for Language Interpretation and Translation“

http://www.languageline.com/industry_healthcare

American Society for Testing and Materials ASTM

Created a document in 2001 that has furthered the understanding of standards for all professional interpreters

The Massachusetts Medical Interpreters Assoc endorsed their documents on the Standard Guide for Language Interpretation Services (F2089-01) in 2006 Identifies quality language interpretation services

Included interpreter qualifications and listening proficiency along with professional conduct including educational requirements

Includes fluency level for professional interpreters such as educated native or full functional speaking and listening proficiency

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Standards from ASTM

157

http://www.imiaweb.org/standards/ASTM.asp

http://www.astm.org/Standards/F2089.htm

158

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Sample Hospital Website Request for Interpreter

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Certified Interpreter Website

161